Anxiety in medical conditions US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Anxiety in medical conditions. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Anxiety in medical conditions US Medical PG Question 1: An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?
- A. Social phobia
- B. Specific phobia
- C. Adjustment disorder
- D. Panic disorder (Correct Answer)
- E. Somatic symptom disorder
Anxiety in medical conditions Explanation: ***Panic disorder***
- The patient experiences **recurrent, unprovoked panic attacks** characterized by palpitations, feelings of dread, and lightheadedness, which align with the diagnostic criteria for panic disorder.
- His behavior of sitting at the back of lecture halls to "quickly escape" indicates **avoidance behaviors** and **anticipatory anxiety** related to potential future attacks, a hallmark of panic disorder.
*Social phobia*
- This condition is characterized by **fear or anxiety about social situations** where the individual might be scrutinized or judged, which is not the primary driver of the patient's symptoms or avoidance behavior.
- While he avoids public situations, his motivation is fear of a panic attack, not fear of social judgment.
*Specific phobia*
- This involves an **intense, irrational fear of a specific object or situation** (e.g., heights, spiders, flying), which does not fit the generalized, unprovoked nature of the patient's panic attacks.
- The patient's symptoms are not tied to a single, clearly defined phobic stimulus.
*Adjustment disorder*
- This diagnosis is typically made when individuals experience **emotional or behavioral symptoms in response to an identifiable stressor**, arising within three months of the onset of the stressor.
- While starting college is a stressor, the patient's panic attacks are recurrent and unprovoked, evolving into a pattern beyond a typical adjustment response, and he has a negative cardiac workup.
*Somatic symptom disorder*
- This involves **distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the symptoms**, such as disproportionate thoughts about the seriousness of one's symptoms or high levels of anxiety about health.
- Although the patient experiences physical symptoms (palpitations), the presence of clear panic attacks, dread, and avoidance behavior points more specifically to panic disorder rather than a primary focus on the somatic symptoms themselves.
Anxiety in medical conditions US Medical PG Question 2: A 35-year-old woman presents with increased anxiety and a reeling sensation. Her complaint started 30 minutes ago with increased sweating and palpitations and is gradually worsening. On examination, the blood pressure was found to be 194/114 mm Hg. She had normal blood pressure at the local pharmacy 5 days ago. She currently works as an event manager and her job involves a lot of stress. The family history is significant for thyroid carcinoma in her father. Which of the following is most likely in this person?
- A. Increased urine metanephrines (Correct Answer)
- B. Decreased C-peptide
- C. Decreased hemoglobin
- D. Decreased TSH levels
- E. Increased serum serotonin
Anxiety in medical conditions Explanation: ***Increased urine metanephrines***
- The patient's symptoms (anxiety, reeling sensation, sweating, palpitations, and paroxysmal hypertension) are highly suggestive of a **pheochromocytoma**, which is a tumor of the adrenal medulla that secretes catecholamines.
- **Metanephrines** (metabolism products of catecholamines) are often elevated in urine and plasma samples from patients with pheochromocytoma, making this the most likely finding.
*Decreased C-peptide*
- **Decreased C-peptide** levels are indicative of reduced endogenous insulin production, typically seen in type 1 diabetes, which does not align with the patient's acute presentation of paroxysmal hypertension and anxiety.
- Her symptoms are not consistent with **hypoglycemia** or **diabetes mellitus**.
*Decreased hemoglobin*
- **Decreased hemoglobin** indicates anemia, which would present with fatigue, pallor, and shortness of breath, not the acute hypertensive crisis and anxiety described.
- There is no clinical information in the vignette to suggest **blood loss** or **red blood cell destruction**.
*Decreased TSH levels*
- **Decreased TSH levels** would suggest hyperthyroidism, which can cause anxiety and palpitations, but the sudden onset and extreme hypertension (194/114 mm Hg) are more characteristic of a **catecholamine surge** than typical hyperthyroidism.
- While there is a family history of **thyroid carcinoma**, the acute presentation points away from purely thyroid-related issues as the primary cause.
*Increased serum serotonin*
- **Increased serum serotonin** is associated with carcinoid syndrome, which typically presents with flushing, diarrhea, bronchospasm, and valvular heart disease, not the predominant features of anxiety, palpitations, and paroxysmal hypertension seen in this patient.
- The symptoms are more consistent with an acute release of **catecholamines**, not serotonin.
Anxiety in medical conditions US Medical PG Question 3: A 25-year-old woman presents with a history of recurrent attacks of unprovoked fear, palpitations, and fainting. The attacks are usually triggered by entering a crowded place or public transport, so the patient tries to avoid being in public places alone. Besides this, she complains of difficulties in falling asleep, uncontrolled worry about her job and health, fear to lose the trust of her friends, and poor appetite. She enjoys dancing and has not lost a passion for her hobby, but recently when she participated in a local competition, she had an attack which made her stop her performance until she calmed down and her condition improved. She feels upset due to her condition. She works as a sales manager and describes her work as demanding with multiple deadlines to be met. She recently broke up with her boyfriend. She does not report any chronic medical problems, but she sometimes takes doxylamine to fall asleep. She has a 4-pack-year history of smoking and drinks alcohol occasionally. On presentation, her blood pressure is 110/60 mm Hg, heart rate is 71/min, respiratory rate is 13/min, and temperature is 36.5°C (97.7°F). Her physical examination is unremarkable. Which of the following medications can be used for the acute management of the patient’s attacks?
- A. Imipramine
- B. Clonazepam (Correct Answer)
- C. Metoprolol
- D. Bupropion
- E. Nifedipine
Anxiety in medical conditions Explanation: ***Clonazepam***
- **Clonazepam** is a **benzodiazepine** that acts rapidly to provide acute relief from severe anxiety symptoms, such as those experienced during a **panic attack**.
- Its fast onset of action and anxiolytic properties make it suitable for interrupting the acute, distressing symptoms of **panic disorder**.
*Imipramine*
- **Imipramine** is a **tricyclic antidepressant** (TCA) and is used for long-term management of panic disorder and depression, but its onset of action is too slow for acute symptom relief.
- TCAs have significant **anticholinergic side effects** and cardiotoxicity, making them less suitable for immediate use in an acute panic attack.
*Metoprolol*
- **Metoprolol** is a **beta-blocker** that can help manage the physical symptoms of anxiety, such as palpitations and tremors, but it does not address the underlying psychological component of panic.
- Beta-blockers are generally not recommended as monotherapy for panic attacks as they do not treat the core anxiety, though they can be useful for performance anxiety.
*Bupropion*
- **Bupropion** is an **atypical antidepressant** primarily used for depression and smoking cessation, but it can sometimes worsen anxiety in patients.
- It works by inhibiting the reuptake of norepinephrine and dopamine, and its stimulant-like effects are not suitable for acute panic relief.
*Nifedipine*
- **Nifedipine** is a **calcium channel blocker** used to treat hypertension and angina, and it has no direct role in the management of panic attacks.
- While it affects cardiovascular function, it does not alleviate the anxiety and fear component of a panic attack.
Anxiety in medical conditions US Medical PG Question 4: A previously healthy 25-year-old woman comes to the physician because of a 1-month history of palpitations that occur on minimal exertion and sometimes at rest. She has no chest discomfort or shortness of breath. She feels nervous and irritable most of the time and attributes these feelings to her boyfriend leaving her 2 months ago. Since then she has started exercising more frequently and taking an herbal weight-loss pill, since which she has lost 6.8 kg (15 lb) of weight. She finds it hard to fall asleep and awakens 1 hour before the alarm goes off each morning. She has been drinking 2 to 3 cups of coffee daily for the past 7 years and has smoked one pack of cigarettes daily for the past 3 years. Her temperature is 37.4°C (99.4°F), pulse is 110/min, respirations are 18/min, and blood pressure is 150/70 mm Hg. Examination shows moist palms. Neurologic examination shows a fine resting tremor of the hands. Deep tendon reflexes are 3+ with a shortened relaxation phase. Which of the following is the most likely cause of this patient's symptoms?
- A. Exogenous hyperthyroidism (Correct Answer)
- B. Pheochromocytoma
- C. Hashimoto thyroiditis
- D. Coffee consumption
- E. Generalized anxiety disorder
Anxiety in medical conditions Explanation: ***Exogenous hyperthyroidism***
- The patient's symptoms including **palpitations, weight loss, nervousness, irritability, insomnia**, and physical findings like **tachycardia, moist palms, fine tremor**, and **hyperreflexia with shortened relaxation phase** are highly indicative of **hyperthyroidism**.
- The use of an **herbal weight-loss pill** strongly suggests the possibility of exogenous thyroid hormone intake or other thyroid-stimulating substances within the pill, leading to **exogenous hyperthyroidism**.
*Pheochromocytoma*
- While **palpitations** and **hypertension** can occur, **pheochromocytoma** is typically characterized by paroxysmal episodes of severe headaches, sweating, and anxiety.
- The chronic nature of the patient's symptoms, along with significant **weight loss** and **hyperreflexia**, are less typical for **pheochromocytoma**.
*Hashimoto thyroiditis*
- **Hashimoto thyroiditis** typically causes **hypothyroidism**, characterized by symptoms like weight gain, fatigue, cold intolerance, and bradycardia.
- While it can sometimes have a transient hyperthyroid phase (hashitoxicosis), the overall clinical picture here is more consistent with sustained **hyperthyroidism**, especially given the suspected external factor.
*Coffee consumption*
- Although **caffeine** can cause palpitations, nervousness, and insomnia, the severity and breadth of this patient's symptoms, including significant **weight loss, hyperreflexia**, and **moist palms**, extend far beyond what would typically be attributed solely to coffee intake, especially given her chronic coffee use.
- The new onset and progression of these symptoms, coinciding with the herbal pill, points to a stronger underlying cause.
*Generalized anxiety disorder*
- **Generalized anxiety disorder (GAD)** can explain nervousness, irritability, and insomnia, but it does not typically cause **significant weight loss** or objective physical findings such as **tachycardia, moist palms, fine tremor, and hyperreflexia**.
- These physical signs are hallmarks of a physiological rather than purely psychological condition.
Anxiety in medical conditions US Medical PG Question 5: A 25-year-old man comes to the physician because of palpitations, sweating, and flushing. Since he was promoted to a manager in a large software company 6 months ago, he has had several episodes of these symptoms when he has to give presentations in front of a large group of people. During these episodes, his thoughts start racing and he fears that his face will “turn red” and everyone will laugh at him. He has tried to avoid the presentations but fears that he might lose his job if he continues to do so. He is healthy except for mild-persistent asthma. He frequently smokes marijuana to calm his nerves. He does not drink alcohol. His only medication is an albuterol inhaler. His pulse is 78/min, respirations are 14/min, and blood pressure is 120/75 mm Hg. Cardiopulmonary examination shows no abnormalities. On mental status examination, the patient appears worried and has a flattened affect. Which of the following is the most appropriate next step in management?
- A. Buspirone therapy
- B. Lorazepam therapy
- C. Duloxetine therapy
- D. Cognitive behavioral therapy (Correct Answer)
- E. Olanzapine therapy
Anxiety in medical conditions Explanation: ***Cognitive behavioral therapy***
- The patient exhibits classic symptoms of **social anxiety disorder (social phobia)**, including anxiety in social situations, fear of judgment, and avoidance behavior, which is a key indication for **CBT**.
- **CBT** is an effective first-line treatment for social anxiety, helping individuals identify and challenge distorted thoughts, and gradually expose themselves to feared social situations.
*Buspirone therapy*
- **Buspirone** is an anxiolytic that can be used for **generalized anxiety disorder**, but it is generally less effective for specific phobias like social anxiety or for acute anxiety attacks.
- Its therapeutic effects can take several weeks to manifest, making it unsuitable for immediate symptom management in highly specific, performance-related anxiety.
*Lorazepam therapy*
- **Lorazepam**, a **benzodiazepine**, can acutely reduce anxiety symptoms but carries risks of **tolerance, dependence, and withdrawal**, especially with frequent use.
- Its potential for abuse, combined with the patient's marijuana use for nerves, makes it a less appropriate first-line choice for long-term management.
*Duloxetine therapy*
- **Duloxetine**, a **serotonin-norepinephrine reuptake inhibitor (SNRI)**, is a pharmacological option for social anxiety disorder, particularly when CBT alone is insufficient.
- While an antidepressant, it is not considered the initial treatment of choice over CBT, which addresses the underlying cognitive and behavioral patterns.
*Olanzapine therapy*
- **Olanzapine** is an **atypical antipsychotic** primarily used for conditions like **schizophrenia** and **bipolar disorder**.
- It is not indicated for social anxiety disorder as a standalone treatment and carries significant side effects, including metabolic disturbances.
Anxiety in medical conditions US Medical PG Question 6: A 43-year-old male with a history of thyroid cancer status post total thyroidectomy presents to his primary care physician after repeated bouts of headaches. His headaches are preceded by periods of anxiety, palpitations, and sweating. The patient says he is unable to pinpoint any precipitating factors and instead says the events occur without warning. Of note, the patient's father and uncle also have a history of thyroid cancer. On exam his vitals are: T 36.8 HR 87, BP 135/93, RR 14, and O2 Sat 100% on room air. The patient's TSH is within normal limits, and he reports taking his levothyroxine as prescribed. What is the next best step in diagnosing this patient's chief complaint?
- A. 24-hour urine free cortisol
- B. Plasma aldosterone/renin ratio
- C. Abdominal CT scan with and without IV contrast
- D. Plasma fractionated metanephrines (Correct Answer)
- E. High dose dexamethasone suppression test
Anxiety in medical conditions Explanation: ***Plasma fractionated metanephrines***
- The patient's symptoms of **anxiety, palpitations, sweating, and headaches** occurring in discrete "attacks" are classic for a **pheochromocytoma**, a tumor that secretes catecholamines.
- Given the patient's and his family's history of **thyroid cancer**, specifically likely **medullary thyroid cancer** due to the familial link, there is a high suspicion for **Multiple Endocrine Neoplasia type 2 (MEN2)**, which commonly includes pheochromocytoma. **Plasma fractionated metanephrines** are the most sensitive screening test for pheochromocytoma.
*24-hour urine free cortisol*
- This test is used to detect **Cushing's syndrome**, which involves excessive cortisol production.
- Although Cushing's can cause **hypertension**, the paroxysmal symptoms of anxiety, palpitations, and sweating are not typical of Cushing's syndrome.
*Plasma aldosterone/renin ratio*
- This ratio is used to screen for **primary hyperaldosteronism**, a cause of secondary hypertension.
- While the patient has **hypertension (135/93 mm Hg)**, his symptom complex of episodic anxiety, palpitations, and sweating is not characteristic of primary hyperaldosteronism.
*Abdominal CT scan with and without IV contrast*
- An abdominal CT scan can visualize adrenal masses, but it is typically performed *after* biochemical confirmation of a pheochromocytoma to localize the tumor.
- Performing imaging before biochemical testing risks incidentalomas or missing a biochemically active but small tumor, and it is not the most appropriate *next step* in diagnosis given the strong clinical suspicion.
*High dose dexamethasone suppression test*
- This test is specifically used to differentiate between **Cushing's disease** (pituitary ACTH excess) and other causes of Cushing's syndrome.
- The patient's symptoms are not consistent with excessive cortisol production, making this test inappropriate for his chief complaint.
Anxiety in medical conditions US Medical PG Question 7: Every time your neighbor in the adjacent apartment flushes the toilet, the water in your shower becomes very hot, causing you to jump out of the way of the water stream. After this has occurred for several months, you note that you reflexively jump back from the water directly after the sound of the flushing toilet but before the water temperature changes. Which of the following situations is the most similar to the conditioning process detailed above?
- A. You consistently check the slots of pay telephones as you have previously found change left there
- B. White coat syndrome (patient anxiety evoked at the sight of a white lab coat) (Correct Answer)
- C. A young child elects to not throw a temper tantrum to avoid being grounded by his parents
- D. A mouse repeatedly presses a red button to avoid receiving an electric shock
- E. You now sleep through the noise of the train running past your apartment that kept you up 1 year ago
Anxiety in medical conditions Explanation: ***White coat syndrome (patient anxiety evoked at the sight of a white lab coat)***
- This is an example of **classical conditioning**, where a neutral stimulus (**white coat**) becomes associated with an unconditioned stimulus (pain/anxiety-inducing medical procedures), leading to a conditioned response (anxiety).
- Similarly, the **sound of the flush** (neutral stimulus) became associated with the **hot water** (unconditioned stimulus), leading to a **reflexive jump** (conditioned response).
*You consistently check the slots of pay telephones as you have previously found change left there*
- This scenario represents **operant conditioning**, specifically **positive reinforcement**, where checking the slot is reinforced by the reward of finding change.
- The behavior is strengthened by the **consequence** that follows it, rather than an association between two stimuli.
*A young child elects to not throw a temper tantrum to avoid being grounded by his parents*
- This is an example of **negative punishment** in **operant conditioning**, where the child avoids a negative consequence (being grounded) by refraining from a specific behavior (tantrum).
- The focus is on the **consequences** of an action influencing future behavior, not an involuntary, learned association between stimuli.
*A mouse repeatedly presses a red button to avoid receiving an electric shock*
- This describes **operant conditioning**, specifically **negative reinforcement**, where the mouse performs an action (**pressing the button**) to remove an aversive stimulus (**electric shock**).
- It involves a voluntary action to escape or avoid an unpleasant event, differing from the involuntary, anticipatory reflex seen in classical conditioning.
*You now sleep through the noise of the train running past your apartment that kept you up 1 year ago*
- This is an example of **habituation**, a non-associative learning process where an organism decreases its response to a stimulus after repeated exposure.
- The organism learns to **ignore** an irrelevant or non-threatening stimulus, rather than forming a new association between two stimuli.
Anxiety in medical conditions US Medical PG Question 8: A goalkeeper of a famous soccer team gives an interview with a health agency regarding his childhood. He describes how when he was a child, he would constantly clear his throat in class and the teachers would write a note to his mother with advice to go see an ENT doctor. He complained of being restless, fidgety, and sometimes hyperactive in class, disrupting the environment and causing him many social problems. He would blurt out the answer at times and keep repeating it without any control, leading to some embarrassing timeouts. But he was always nice to his teachers, so he calls it a “benign frustration” rather than aggressively causing distress. He also talked about how his symptoms were dramatically improved with medication. Which of the following is an FDA approved drug for this patient’s most likely condition?
- A. Lithium
- B. Clonazepam
- C. Haloperidol (Correct Answer)
- D. Clonidine
- E. Guanfacine
Anxiety in medical conditions Explanation: ***Haloperidol***
- The patient's presentation of constant throat clearing (**motor tics**), blurting out answers and repeating words (**vocal tics**), along with restlessness and hyperactivity, is highly suggestive of **Tourette syndrome**.
- **Haloperidol** is one of the **FDA-approved medications** specifically for Tourette syndrome, along with pimozide and aripiprazole.
- It is a **typical antipsychotic** that effectively treats severe tics through **dopamine D2 receptor blockade**, particularly in the nigrostriatal pathway.
- It remains a gold standard treatment despite potential extrapyramidal side effects.
*Lithium*
- **Lithium** is a **mood stabilizer** used primarily for **bipolar disorder** through its effects on intracellular signaling pathways.
- It has no role in treating Tourette syndrome or tic disorders and is not FDA-approved for this indication.
*Clonazepam*
- **Clonazepam** is a **benzodiazepine** with **GABAergic effects** used for **anxiety disorders**, **panic disorder**, and certain seizure disorders.
- While it may help with comorbid anxiety, it is not a primary treatment for tics and is **not FDA-approved** for Tourette syndrome.
*Clonidine*
- **Clonidine** is an **alpha-2 adrenergic agonist** that can reduce tics, particularly in children with mild to moderate symptoms or comorbid ADHD.
- However, it is **off-label** for Tourette syndrome and not FDA-approved for this indication, though commonly used as a second-line agent.
*Guanfacine*
- **Guanfacine** is also an **alpha-2 adrenergic agonist** similar to clonidine, used primarily for ADHD.
- It may help with tics in an **off-label capacity**, especially when ADHD is comorbid, but it is **not FDA-approved** specifically for Tourette syndrome.
Anxiety in medical conditions US Medical PG Question 9: A 22-year-old woman is in her last few months at community college. She has a very important essay due in 2 weeks that will play a big part in determining her final grades. She decides to focus on writing this essay instead and not to worry about her grades until her essay is completed. Which of the following defense mechanisms best explains her behavior?
- A. Suppression (Correct Answer)
- B. Blocking
- C. Denial
- D. Dissociation
- E. Repression
Anxiety in medical conditions Explanation: ***Suppression***
- This defense mechanism involves the **conscious decision** to temporarily push unacceptable thoughts, feelings, or impulses out of awareness. The student is choosing to not worry about her grades *for now* to focus on the essay.
- It is a **mature defense mechanism** where the individual is aware of the situation but actively postpones thinking about it to address a more immediate task.
*Blocking*
- **Blocking** refers to a temporary inability to remember or think of something.
- It is usually an **unconscious and involuntary** mental process, distinct from the conscious choice made in the scenario.
*Denial*
- **Denial** involves refusing to acknowledge an obvious truth or reality, often an unpleasant one.
- The student is not denying that grades are important or that she will eventually worry about them; she is simply **postponing** the worry.
*Dissociation*
- **Dissociation** involves a disruption of the usually integrated functions of consciousness, memory, identity, or perception.
- This can manifest as an **altered sense of self or reality**, which is not described in the student's focused behavior.
*Repression*
- **Repression** is an **unconscious defense mechanism** where unacceptable thoughts, feelings, or memories are involuntarily pushed out of conscious awareness.
- Unlike suppression, which is conscious, repression is an **automatic and unconscious process**, and the student's decision here is a deliberate one.
Anxiety in medical conditions US Medical PG Question 10: A 23-year-old man is brought to the emergency department by the police after attempting to assault a waiter with a broom. The patient states that the FBI has been following him his entire life and that this man was an agent spying on him. The patient has a past medical history of irritable bowel syndrome. His temperature is 98.0°F (36.7°C), blood pressure is 137/68 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is deferred due to patient combativeness. The patient is given haloperidol and diphenhydramine. The patient is later seen in his room still agitated. Intraosseous access is obtained. Which of the following is the best next step in management?
- A. Complete blood count
- B. Urine toxicology (Correct Answer)
- C. Thyroid stimulating hormone level
- D. Assess for suicidal ideation
- E. Syphilis screening
Anxiety in medical conditions Explanation: ***Urine toxicology***
- A definitive diagnosis of **substance-induced psychosis** or **agitation** can be made through a urine toxicology screen, which is crucial given the patient's acute agitated state and paranoid delusions.
- Identification of specific substances helps guide further management, as some intoxicants or withdrawal states require targeted interventions.
*Complete blood count*
- While a CBC assesses for infection or anemia, it is unlikely to reveal the primary cause of acute **agitation** and **paranoid delusions** in this context.
- This diagnostic test would be more relevant if there were signs of infection (e.g., fever, localized pain) or significant blood loss.
*Thyroid stimulating hormone level*
- Although **thyroid dysfunction** can cause psychiatric symptoms, it typically manifests more gradually and rarely presents with such an acute onset of severe **agitation** and **paranoia**.
- Other clinical signs of thyroid dysfunction, such as weight changes or altered energy levels, are also absent.
*Assess for suicidal ideation*
- While important in any psychiatric evaluation, assessing for **suicidal ideation** is a part of mental status examination. Given the patient's current severe agitation and combativeness, obtaining a reliable assessment of suicidal ideation is extremely difficult and secondary to managing the acute behavioral crisis and identifying immediate medical causes.
- The immediate priority is to understand the etiology of his acute behavioral disturbance and ensure safety, before a full psychiatric history can be reliably obtained.
*Syphilis screening*
- **Neurosyphilis** can cause neuropsychiatric symptoms, including psychosis, but it is typically a chronic condition with a more insidious onset.
- In an acutely agitated patient with sudden onset of paranoid delusions, syphilis is a less likely immediate cause compared to substance use.
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